Provider Demographics
NPI:1558450064
Name:HEDGEPETH, MICHAEL CLINTON (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CLINTON
Last Name:HEDGEPETH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5858 CREEKWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5416
Mailing Address - Country:US
Mailing Address - Phone:210-590-6953
Mailing Address - Fax:
Practice Address - Street 1:8401 DATAPOINT DR
Practice Address - Street 2:SUITE 500
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5900
Practice Address - Country:US
Practice Address - Phone:210-614-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02868OtherTEXAS STATE BOARD LICENSE